Meta-Analysis of the Effect of Automated Contrast Injection Devices Versus Manual Injection and Contrast Volume on Risk of Contrast-Induced Nephropathy
2013; Elsevier BV; Volume: 113; Issue: 1 Linguagem: Inglês
10.1016/j.amjcard.2013.08.040
ISSN1879-1913
AutoresKristopher D. Minsinger, Hayah Kassis, Clay A. Block, Mandeep S. Sidhu, Jeremiah R. Brown,
Tópico(s)Dialysis and Renal Disease Management
ResumoContrast-sparing devices have been slowly adopted into routine patient care. Randomized trial evidence of automated contrast injectors (ACIs) has not been analyzed to evaluate the true reduction in contrast volume during coronary angiography and intervention. It has been thought that reducing the amount of contrast exposure will result in a simultaneous reduction in the risk of contrast-induced nephropathy (CIN). Therefore, we sought to synthesize published evidence on contrast-sparing devices, contrast volume, and the incidence of CIN. We searched Medline, the Cochrane Library, and Clinicaltrials.gov. The search criteria included ACIs versus manual injection, contrast media volume, and the incidence of CIN. Data were extracted by 2 independent reviewers. The weighted mean difference of contrast volume was calculated using random effects models in RevMan, version 5.4.1, software to derive a summary estimate. A total of 79,694 patients from 10 studies were included (ACI arm, n = 20,099; manual injection arm, n = 59,595). On average, ACIs reduced contrast volume delivery by 45 ml/case (p <0.001, 95% confidence interval −54 to −35). The CIN incidence was significantly reduced by 15%, with an odds ratio of 0.85 (p <0.001, 95% confidence interval 0.78 to 0.93) for those using ACIs compared with manual injection. In conclusion, the use of ACIs in angiography significantly reduces the volume of contrast delivered to the patient and the incidence of CIN. Contrast-sparing devices have been slowly adopted into routine patient care. Randomized trial evidence of automated contrast injectors (ACIs) has not been analyzed to evaluate the true reduction in contrast volume during coronary angiography and intervention. It has been thought that reducing the amount of contrast exposure will result in a simultaneous reduction in the risk of contrast-induced nephropathy (CIN). Therefore, we sought to synthesize published evidence on contrast-sparing devices, contrast volume, and the incidence of CIN. We searched Medline, the Cochrane Library, and Clinicaltrials.gov. The search criteria included ACIs versus manual injection, contrast media volume, and the incidence of CIN. Data were extracted by 2 independent reviewers. The weighted mean difference of contrast volume was calculated using random effects models in RevMan, version 5.4.1, software to derive a summary estimate. A total of 79,694 patients from 10 studies were included (ACI arm, n = 20,099; manual injection arm, n = 59,595). On average, ACIs reduced contrast volume delivery by 45 ml/case (p <0.001, 95% confidence interval −54 to −35). The CIN incidence was significantly reduced by 15%, with an odds ratio of 0.85 (p <0.001, 95% confidence interval 0.78 to 0.93) for those using ACIs compared with manual injection. In conclusion, the use of ACIs in angiography significantly reduces the volume of contrast delivered to the patient and the incidence of CIN. To date, several studies have compared manual injection and automated contrast injectors (ACIs) and have reported a reduction in contrast volume administered with use of ACIs.1Anne G. Gruberg L. Huber A. Nikolsky E. Grenadier E. Boulus M. Amikam S. Markiewicz W. Beyar R. Traditional versus automated injection contrast system in diagnostic and percutaneous coronary interventional procedures: comparison of the contrast volume delivered.J Invasive Cardiol. 2004; 16: 360-362PubMed Google Scholar, 2Brosh D. Assali A. Vaknin-Assa H. Fuchs S. Teplitsky I. Shor N. Kornowski R. The ACIST power injection system reduces the amount of contrast media delivered to the patient, as well as fluoroscopy time, during diagnostic and interventional cardiac procedures.Int J Cardiovasc Intervent. 2005; 7: 183-187PubMed Google Scholar, 3Call J. Sacrinty M. Applegate R. Little W. Santos R. Baki T. Gandhi S. Kahl F. Kutcher M. Automated contrast injection in contemporary practice during cardiac catheterization and PCI: effects on contrast-induced nephropathy.J Invasive Cardiol. 2006; 18: 469-474PubMed Google Scholar, 4Chahoud G. Khoukaz S. El-Shafei A. Azrak E. Bitar S. Kern M.J. Randomized comparison of coronary angiography using 4F catheters: 4F manual versus "Acisted" power injection technique.Catheter Cardiovasc Interv. 2001; 53: 221-224Crossref PubMed Scopus (25) Google Scholar, 5Gurm H.S. Smith D. Share D. Wohns D. Collins J. Madala M. Koneru S. Menees D. Chetcuti S. Impact of automated contrast injector systems on contrast use and contrast-associated complications in patients undergoing percutaneous coronary interventions.JACC Cardiovasc Interv. 2013; 6: 399-405Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar, 6Hou L. Wei Y.D. Song J. Che W.L. Peng W.H. Wang Y. Li W.M. Xu Y.W. Hu D.Y. Comparative study of 4Fr catheters using the ACIST variable rate injector system versus 6Fr catheters using hand manifold in diagnostic coronary angiography via transradial approach.Chin Med J (Engl). 2010; 123: 1373-1376PubMed Google Scholar, 7Khoukaz S. Kern M.J. Bitar S.R. Azrak E. Eisenhauer M. Wolford T. El-Shafei A. Coronary angiography using 4 Fr catheters with acisted power injection: a randomized comparison to 6 Fr manual technique and early ambulation.Catheter Cardiovasc Interv. 2001; 52: 393-398Crossref PubMed Scopus (31) Google Scholar The studies have varied in the reported reduction of contrast for diagnostic catheterization.1Anne G. Gruberg L. Huber A. Nikolsky E. Grenadier E. Boulus M. Amikam S. Markiewicz W. Beyar R. Traditional versus automated injection contrast system in diagnostic and percutaneous coronary interventional procedures: comparison of the contrast volume delivered.J Invasive Cardiol. 2004; 16: 360-362PubMed Google Scholar, 2Brosh D. Assali A. Vaknin-Assa H. Fuchs S. Teplitsky I. Shor N. Kornowski R. The ACIST power injection system reduces the amount of contrast media delivered to the patient, as well as fluoroscopy time, during diagnostic and interventional cardiac procedures.Int J Cardiovasc Intervent. 2005; 7: 183-187PubMed Google Scholar, 3Call J. Sacrinty M. Applegate R. Little W. Santos R. Baki T. Gandhi S. Kahl F. Kutcher M. Automated contrast injection in contemporary practice during cardiac catheterization and PCI: effects on contrast-induced nephropathy.J Invasive Cardiol. 2006; 18: 469-474PubMed Google Scholar, 4Chahoud G. Khoukaz S. El-Shafei A. Azrak E. Bitar S. Kern M.J. Randomized comparison of coronary angiography using 4F catheters: 4F manual versus "Acisted" power injection technique.Catheter Cardiovasc Interv. 2001; 53: 221-224Crossref PubMed Scopus (25) Google Scholar, 6Hou L. Wei Y.D. Song J. Che W.L. Peng W.H. Wang Y. Li W.M. Xu Y.W. Hu D.Y. Comparative study of 4Fr catheters using the ACIST variable rate injector system versus 6Fr catheters using hand manifold in diagnostic coronary angiography via transradial approach.Chin Med J (Engl). 2010; 123: 1373-1376PubMed Google Scholar, 7Khoukaz S. Kern M.J. Bitar S.R. Azrak E. Eisenhauer M. Wolford T. El-Shafei A. Coronary angiography using 4 Fr catheters with acisted power injection: a randomized comparison to 6 Fr manual technique and early ambulation.Catheter Cardiovasc Interv. 2001; 52: 393-398Crossref PubMed Scopus (31) Google Scholar, 8Gonzalez M.A. Ben-Dor I. Gaglia Jr., M.A. Torguson R. Shimellis H. Bui A. Suddath W.O. Pichard A.D. Satler L.F. Waksman R. Qualitative comparison of coronary angiograms between 4 French catheters with an advanced cardiovascular injection system and 6 French catheters with manual injection.Catheter Cardiovasc Interv. 2012; 79: 843-848Crossref PubMed Scopus (5) Google Scholar, 9Hwang J.R. D'Alfonso S. Kostuk W.J. Diamantouros P. Teefy P. Jablonsky G. Lavi S. Contrast volume use in manual vs automated contrast injection systems for diagnostic coronary angiography and percutaneous coronary interventions.Can J Cardiol. 2013; 29: 372-376Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar Others have also included the contrast volume used during percutaneous coronary intervention (PCI).1Anne G. Gruberg L. Huber A. Nikolsky E. Grenadier E. Boulus M. Amikam S. Markiewicz W. Beyar R. Traditional versus automated injection contrast system in diagnostic and percutaneous coronary interventional procedures: comparison of the contrast volume delivered.J Invasive Cardiol. 2004; 16: 360-362PubMed Google Scholar, 2Brosh D. Assali A. Vaknin-Assa H. Fuchs S. Teplitsky I. Shor N. Kornowski R. The ACIST power injection system reduces the amount of contrast media delivered to the patient, as well as fluoroscopy time, during diagnostic and interventional cardiac procedures.Int J Cardiovasc Intervent. 2005; 7: 183-187PubMed Google Scholar, 3Call J. Sacrinty M. Applegate R. Little W. Santos R. Baki T. Gandhi S. Kahl F. Kutcher M. Automated contrast injection in contemporary practice during cardiac catheterization and PCI: effects on contrast-induced nephropathy.J Invasive Cardiol. 2006; 18: 469-474PubMed Google Scholar, 4Chahoud G. Khoukaz S. El-Shafei A. Azrak E. Bitar S. Kern M.J. Randomized comparison of coronary angiography using 4F catheters: 4F manual versus "Acisted" power injection technique.Catheter Cardiovasc Interv. 2001; 53: 221-224Crossref PubMed Scopus (25) Google Scholar, 5Gurm H.S. Smith D. Share D. Wohns D. Collins J. Madala M. Koneru S. Menees D. Chetcuti S. Impact of automated contrast injector systems on contrast use and contrast-associated complications in patients undergoing percutaneous coronary interventions.JACC Cardiovasc Interv. 2013; 6: 399-405Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar, 7Khoukaz S. Kern M.J. Bitar S.R. Azrak E. Eisenhauer M. Wolford T. El-Shafei A. Coronary angiography using 4 Fr catheters with acisted power injection: a randomized comparison to 6 Fr manual technique and early ambulation.Catheter Cardiovasc Interv. 2001; 52: 393-398Crossref PubMed Scopus (31) Google Scholar, 9Hwang J.R. D'Alfonso S. Kostuk W.J. Diamantouros P. Teefy P. Jablonsky G. Lavi S. Contrast volume use in manual vs automated contrast injection systems for diagnostic coronary angiography and percutaneous coronary interventions.Can J Cardiol. 2013; 29: 372-376Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar However, a significant gap exists in summarizing the evidence from the published data. With several studies reporting varying results in the use of ACIs compared with manual injection, a meta-analysis or systematic review of the current research was required. The sample size of several of the studies was small, and the combined power of a meta-analysis could allow for a more powerful conclusion from the evidence. Therefore, we conducted a meta-analysis examining the currently published evidence on the reduction of contrast volume and the possible reduction of contrast-induced nephropathy (CIN) with the use of ACIs versus manual injection. Several studies have reported the effects of ACIs on the volume of contrast used during coronary angiography; fewer studies have examined the effects of contrast volume on renal function. We hypothesized that (1) contrast-sparing devices would reduce the total contrast volume used during diagnostic and interventional cases; and (2) through the reduction of contrast volume, the incidence of CIN would also be reduced. We searched MEDLINE (through April 2013), ClinicalTrials.gov, and the Cochrane Library, for clinical trials comparing ACIs and manual injection and whether the contrast media volume and/or CIN rates had been reported. As of April 2013, 62 potentially relevant reports were identified. We also did a manual search on the cross-references included in the present meta-analysis. Key word MESH terms included "automated injection," "manual injection," "automated contrast injectors," and "ACIST" for the ACIST Injection System (ACIST Medical Systems, Eden Prairie, Minnesota). The studies were included if they compared the amount of contrast volume delivery between ACIs and manual manifold injection systems in patients undergoing diagnostic coronary angiography and/or ad hoc PCI. The exclusion criteria were the absence of a manual injection arm or failing to report the delivered contrast volume. The data were abstracted using appropriate methods according to the Quality of Reporting of Meta-analysis statement.10Moher D. Cook D.J. Eastwood S. Olkin I. Rennie D. Stroup D.F. Improving the quality of reports of meta-analyses of randomised controlled trials: the QUOROM statement. Quality of Reporting of Meta-analyses.Lancet. 1999; 354: 1896-1900Abstract Full Text Full Text PDF PubMed Scopus (3896) Google Scholar Two of us (K.M., H.K.) independently reviewed the studies and recorded the information outcomes on spreadsheets. Study quality was assessed using the Jadad criteria (Table 1).11Jadad A.R. Moore R.A. Carroll D. Jenkinson C. Reynolds D.J. Gavaghan D.J. McQuay H.J. Assessing the quality of reports of randomized clinical trials: is blinding necessary?.Control Clin Trials. 1996; 17: 1-12Abstract Full Text PDF PubMed Scopus (13223) Google ScholarTable 1Study characteristicsStudyInterventionPatients (n)ProtocolEnrollment CriteriaStudy TypeRCTJadad ScoreAnne et al,1Anne G. Gruberg L. Huber A. Nikolsky E. Grenadier E. Boulus M. Amikam S. Markiewicz W. Beyar R. Traditional versus automated injection contrast system in diagnostic and percutaneous coronary interventional procedures: comparison of the contrast volume delivered.J Invasive Cardiol. 2004; 16: 360-362PubMed Google Scholar 2004Automated injection253Contrast injection with ACIST deviceCatheterization and/or PCIProspective+2Manual injection200Manual contrast injection using stopcock-manifold systemBrosh et al,2Brosh D. Assali A. Vaknin-Assa H. Fuchs S. Teplitsky I. Shor N. Kornowski R. The ACIST power injection system reduces the amount of contrast media delivered to the patient, as well as fluoroscopy time, during diagnostic and interventional cardiac procedures.Int J Cardiovasc Intervent. 2005; 7: 183-187PubMed Google Scholar 2005Automated injection117Contrast injection with ACIST deviceCatheterization and angiography or PCIProspective+1Manual injection95Manual injection with hand syringeCall et al,3Call J. Sacrinty M. Applegate R. Little W. Santos R. Baki T. Gandhi S. Kahl F. Kutcher M. Automated contrast injection in contemporary practice during cardiac catheterization and PCI: effects on contrast-induced nephropathy.J Invasive Cardiol. 2006; 18: 469-474PubMed Google Scholar 2006Automated injection377ACICatheterization and PCIRetrospective observational01Manual injection1,798Manual injection with hand syringeChahoud et al,4Chahoud G. Khoukaz S. El-Shafei A. Azrak E. Bitar S. Kern M.J. Randomized comparison of coronary angiography using 4F catheters: 4F manual versus "Acisted" power injection technique.Catheter Cardiovasc Interv. 2001; 53: 221-224Crossref PubMed Scopus (25) Google Scholar 2001Automated injection47Contrast injection using 4F ACIST deviceCatheterization and coronary arteriographyProspective+1Manual injection49Manual injection with 4F catheterGodley et al,13Brown J.R. Birkmeyer N.J. O'Connor G.T. Meta-analysis comparing the effectiveness and adverse outcomes of antifibrinolytic agents in cardiac surgery.Circulation. 2007; 115: 2801-2813Crossref PubMed Scopus (241) Google Scholar 2012Automated injection7,970Contrast injection using ACIST deviceCatheterization and ad hoc PCIRetrospective observational01Manual injection5,137Manual injectionGonzalez et al,8Gonzalez M.A. Ben-Dor I. Gaglia Jr., M.A. Torguson R. Shimellis H. Bui A. Suddath W.O. Pichard A.D. Satler L.F. Waksman R. Qualitative comparison of coronary angiograms between 4 French catheters with an advanced cardiovascular injection system and 6 French catheters with manual injection.Catheter Cardiovasc Interv. 2012; 79: 843-848Crossref PubMed Scopus (5) Google Scholar 2010Automated injection80Contrast injection using 4F catheterCatheterizationProspective+1Manual injection84Manual injection with 6F catheterGurm et al,5Gurm H.S. Smith D. Share D. Wohns D. Collins J. Madala M. Koneru S. Menees D. Chetcuti S. Impact of automated contrast injector systems on contrast use and contrast-associated complications in patients undergoing percutaneous coronary interventions.JACC Cardiovasc Interv. 2013; 6: 399-405Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar 2013Automated injection9,995Automated injection with ACIST; catheter size per operator preferencePCIPropensity matching retrospective observational01Manual injection50,889Manual injection; catheter size per operator preferenceHwang et al,9Hwang J.R. D'Alfonso S. Kostuk W.J. Diamantouros P. Teefy P. Jablonsky G. Lavi S. Contrast volume use in manual vs automated contrast injection systems for diagnostic coronary angiography and percutaneous coronary interventions.Can J Cardiol. 2013; 29: 372-376Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar 2013Automated injection306Contrast injection using Avanta Fluid Management injection system (MEDRAD, INC., Warrendale, Pennsylvania)Catheterization and ad hoc PCIProspective+1Manual injection1,052Manual injection with 6F catheterHou et al,6Hou L. Wei Y.D. Song J. Che W.L. Peng W.H. Wang Y. Li W.M. Xu Y.W. Hu D.Y. Comparative study of 4Fr catheters using the ACIST variable rate injector system versus 6Fr catheters using hand manifold in diagnostic coronary angiography via transradial approach.Chin Med J (Engl). 2010; 123: 1373-1376PubMed Google Scholar 2010Automated injection856Contrast injection using 4F ACIST deviceCoronary angiographyProspective00Manual injection960Manual injection with 6F catheterKhoukaz et al,7Khoukaz S. Kern M.J. Bitar S.R. Azrak E. Eisenhauer M. Wolford T. El-Shafei A. Coronary angiography using 4 Fr catheters with acisted power injection: a randomized comparison to 6 Fr manual technique and early ambulation.Catheter Cardiovasc Interv. 2001; 52: 393-398Crossref PubMed Scopus (31) Google Scholar 2001Automated injection47Contrast injection using 4F ACIST deviceCatheterization and coronary arteriographyProspective+1Manual injection46Manual injection with 6F catheter Open table in a new tab Summary statistics were calculated using the Cochrane Collaborative software, RevMan, version 5.4.1 (Baltimore, Maryland). We tested for heterogeneity using the I2 test.12Henry D.A. Moxey A.J. Carless P.A. O'Connell D. McClelland B. Henderson K.M. Sly K. Laupacis A. Fergusson D. Anti-fibrinolytic use for minimising perioperative allogeneic blood transfusion.Cochrane Database Syst Rev. 2001; : CD001886PubMed Google Scholar Heterogeneity was observed in the diagnostic and ad hoc comparisons. Therefore, a random effects model was used to account for the existing heterogeneity across the studies. The weighted mean difference and 95% confidence intervals (CIs) were calculated for the contrast volume delivered and fluoroscopy time. The methods used for the calculation have been previously described.12Henry D.A. Moxey A.J. Carless P.A. O'Connell D. McClelland B. Henderson K.M. Sly K. Laupacis A. Fergusson D. Anti-fibrinolytic use for minimising perioperative allogeneic blood transfusion.Cochrane Database Syst Rev. 2001; : CD001886PubMed Google Scholar, 13Brown J.R. Birkmeyer N.J. O'Connor G.T. Meta-analysis comparing the effectiveness and adverse outcomes of antifibrinolytic agents in cardiac surgery.Circulation. 2007; 115: 2801-2813Crossref PubMed Scopus (241) Google Scholar We retrieved 62 studies that reported on cardiac catheterization, ACIs, the prevention of CIN, the use of contrast in other diagnostic cardiac modalities, including magnetic resonance imaging and angiography. Of these, 42 were excluded, because they did not meet the inclusion criteria or report on coronary angiography. Thus, 20 studies were reviewed for more detailed information, and 10 withdrawn, because they have not included a comparison arm or report on the contrast volume (Figure 1). The Jadad scores ranged from 0 to 2 (Table 1). Finally, 10 studies met our inclusion criteria and were included in the present analysis (Table 1).1Anne G. Gruberg L. Huber A. Nikolsky E. Grenadier E. Boulus M. Amikam S. Markiewicz W. Beyar R. Traditional versus automated injection contrast system in diagnostic and percutaneous coronary interventional procedures: comparison of the contrast volume delivered.J Invasive Cardiol. 2004; 16: 360-362PubMed Google Scholar, 2Brosh D. Assali A. Vaknin-Assa H. Fuchs S. Teplitsky I. Shor N. Kornowski R. The ACIST power injection system reduces the amount of contrast media delivered to the patient, as well as fluoroscopy time, during diagnostic and interventional cardiac procedures.Int J Cardiovasc Intervent. 2005; 7: 183-187PubMed Google Scholar, 3Call J. Sacrinty M. Applegate R. Little W. Santos R. Baki T. Gandhi S. Kahl F. Kutcher M. Automated contrast injection in contemporary practice during cardiac catheterization and PCI: effects on contrast-induced nephropathy.J Invasive Cardiol. 2006; 18: 469-474PubMed Google Scholar, 4Chahoud G. Khoukaz S. El-Shafei A. Azrak E. Bitar S. Kern M.J. Randomized comparison of coronary angiography using 4F catheters: 4F manual versus "Acisted" power injection technique.Catheter Cardiovasc Interv. 2001; 53: 221-224Crossref PubMed Scopus (25) Google Scholar, 5Gurm H.S. Smith D. Share D. Wohns D. Collins J. Madala M. Koneru S. Menees D. Chetcuti S. Impact of automated contrast injector systems on contrast use and contrast-associated complications in patients undergoing percutaneous coronary interventions.JACC Cardiovasc Interv. 2013; 6: 399-405Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar, 6Hou L. Wei Y.D. Song J. Che W.L. Peng W.H. Wang Y. Li W.M. Xu Y.W. Hu D.Y. Comparative study of 4Fr catheters using the ACIST variable rate injector system versus 6Fr catheters using hand manifold in diagnostic coronary angiography via transradial approach.Chin Med J (Engl). 2010; 123: 1373-1376PubMed Google Scholar, 7Khoukaz S. Kern M.J. Bitar S.R. Azrak E. Eisenhauer M. Wolford T. El-Shafei A. Coronary angiography using 4 Fr catheters with acisted power injection: a randomized comparison to 6 Fr manual technique and early ambulation.Catheter Cardiovasc Interv. 2001; 52: 393-398Crossref PubMed Scopus (31) Google Scholar, 8Gonzalez M.A. Ben-Dor I. Gaglia Jr., M.A. Torguson R. Shimellis H. Bui A. Suddath W.O. Pichard A.D. Satler L.F. Waksman R. Qualitative comparison of coronary angiograms between 4 French catheters with an advanced cardiovascular injection system and 6 French catheters with manual injection.Catheter Cardiovasc Interv. 2012; 79: 843-848Crossref PubMed Scopus (5) Google Scholar, 9Hwang J.R. D'Alfonso S. Kostuk W.J. Diamantouros P. Teefy P. Jablonsky G. Lavi S. Contrast volume use in manual vs automated contrast injection systems for diagnostic coronary angiography and percutaneous coronary interventions.Can J Cardiol. 2013; 29: 372-376Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar, 14Godley II, R.W. Joshi K. Breall J.A. A comparison of the use of traditional hand injection versus automated contrast injectors during cardiac catheterization.J Invasive Cardiol. 2012; 24: 628-630PubMed Google Scholar A total of 79,694 patients were included: 20,099 patients in the ACI arm and 59,595 patients in the manual contrast injection arm. The demographics were similar among all the studies, and no gender-related differences were reported. Of the 10 studies, 6 were randomized controlled trials, 3 were retrospective cohorts, and 1 had divided patients according to the preference of the intervening cardiologist. Three different procedures were performed, including diagnostic coronary angiography, diagnostic angiography with ad hoc PCI, and PCI only (Figure 2). Overall, the contrast volume was reduced by 45 ml (Figure 2) when using ACIs compared with manual injection. The incidence of CIN was reduced in the ACI group by 15% (Figure 3). ACIs resulted in a nonsignificant reduction in CIN after diagnostic coronary angiography and ad hoc PCI and a nonsignificant reduction of CIN after PCI alone. We conducted a meta-analysis to evaluate the contrast volume administered using ACI systems compared with manual injection. Overall, ACIs reduced the contrast volume delivered by 45 ml and reduced the incidence of CIN by 15%. ACIs have been reported to deliver less contrast volume during cardiac catheterization while maintaining image quality. It is likely that the reduction in contrast volume delivered using ACIs could reduce the patient's risk of CIN.15Bartorelli A.L. Marenzi G. Contrast-induced nephropathy.J Interv Cardiol. 2008; 21: 74-85Crossref PubMed Scopus (89) Google Scholar, 16Brown J.R. Robb J.F. Block C.A. Schoolwerth A.C. Kaplan A.V. O'Connor G.T. Solomon R.J. Malenka D.J. Does safe dosing of iodinated contrast prevent contrast-induced acute kidney injury?.Circ Cardiovasc Interv. 2010; 3: 346-350Crossref PubMed Scopus (114) Google Scholar, 17Mehran R. Aymong E.D. Nikolsky E. Lasic Z. Iakovou I. Fahy M. Mintz G.S. Lansky A.J. Moses J.W. Stone G.W. Leon M.B. Dangas G. A simple risk score for prediction of contrast-induced nephropathy after percutaneous coronary intervention: development and initial validation.J Am Coll Cardiol. 2004; 44: 1393-1399PubMed Scopus (0) Google Scholar As shown by Call et al,3Call J. Sacrinty M. Applegate R. Little W. Santos R. Baki T. Gandhi S. Kahl F. Kutcher M. Automated contrast injection in contemporary practice during cardiac catheterization and PCI: effects on contrast-induced nephropathy.J Invasive Cardiol. 2006; 18: 469-474PubMed Google Scholar 108 ml (95% CI −127 to −89) less contrast was used, with a 31.1% relative reduction in the incidence of CIN when ACIs were used for diagnostic catheterization and ad hoc PCI. The incidence of CIN was reduced in the ACI group, with an overall odds ratio of 0.85 (p <0.001, 95% CI 0.78 to 0.93, Figure 3). The use of ACIs resulted in a nonsignificant reduction in CIN, with an odds ratio of 0.81 (p = 0.16, 95% CI 0.60 to 1.08), after diagnostic coronary angiography, a significant reduction of 0.75 (p <0.001, 95% CI 0.63 to 0.90) after diagnostic procedures and PCI, and a nonsignificant reduction of 0.90 (p = 0.08, 95% CI 0.80 to 1.01) after PCI only compared with a manual manifold. The precise pathophysiology has not been established, although contrast media-induced renal vasoconstriction, direct tubular toxicity, lipid peroxidation, and erythrocyte aggregation could be underlying mechanisms.15Bartorelli A.L. Marenzi G. Contrast-induced nephropathy.J Interv Cardiol. 2008; 21: 74-85Crossref PubMed Scopus (89) Google Scholar Four studies compared the outcomes according to catheter size; only 1 compared 4F catheters used in both arms, and 3 reported differences between 6F catheters used in the manual manifold systems and 4F catheters used with ACIs.4Chahoud G. Khoukaz S. El-Shafei A. Azrak E. Bitar S. Kern M.J. Randomized comparison of coronary angiography using 4F catheters: 4F manual versus "Acisted" power injection technique.Catheter Cardiovasc Interv. 2001; 53: 221-224Crossref PubMed Scopus (25) Google Scholar, 6Hou L. Wei Y.D. Song J. Che W.L. Peng W.H. Wang Y. Li W.M. Xu Y.W. Hu D.Y. Comparative study of 4Fr catheters using the ACIST variable rate injector system versus 6Fr catheters using hand manifold in diagnostic coronary angiography via transradial approach.Chin Med J (Engl). 2010; 123: 1373-1376PubMed Google Scholar, 7Khoukaz S. Kern M.J. Bitar S.R. Azrak E. Eisenhauer M. Wolford T. El-Shafei A. Coronary angiography using 4 Fr catheters with acisted power injection: a randomized comparison to 6 Fr manual technique and early ambulation.Catheter Cardiovasc Interv. 2001; 52: 393-398Crossref PubMed Scopus (31) Google Scholar, 8Gonzalez M.A. Ben-Dor I. Gaglia Jr., M.A. Torguson R. Shimellis H. Bui A. Suddath W.O. Pichard A.D. Satler L.F. Waksman R. Qualitative comparison of coronary angiograms between 4 French catheters with an advanced cardiovascular injection system and 6 French catheters with manual injection.Catheter Cardiovasc Interv. 2012; 79: 843-848Crossref PubMed Scopus (5) Google Scholar One study found no difference in the amount of contrast volume delivery, and 3 reported significantly less contrast volume used with the 4F automated injection compared with the manual technique.4Chahoud G. Khoukaz S. El-Shafei A. Azrak E. Bitar S. Kern M.J. Randomized comparison of coronary angiography using 4F catheters: 4F manual versus "Acisted" power injection technique.Catheter Cardiovasc Interv. 2001; 53: 221-224Crossref PubMed Scopus (25) Google Scholar, 6Hou L. Wei Y.D. Song J. Che W.L. Peng W.H. Wang Y. Li W.M. Xu Y.W. Hu D.Y. Comparative study of 4Fr catheters using the ACIST variable rate injector system versus 6Fr catheters using hand manifold in diagnostic coronary angiography via transradial approach.Chin Med J (Engl). 2010; 123: 1373-1376PubMed Google Scholar, 7Khoukaz S. Kern M.J. Bitar S.R. Azrak E. Eisenhauer M. Wolford T. El-Shafei A. Coronary angiography using 4 Fr catheters with acisted power injection: a randomized comparison to 6 Fr manual technique and early ambulation.Catheter Cardiovasc Interv. 2001; 52: 393-398Crossref PubMed Scopus (31) Google Scholar Overall, 5.53 ml (p = 0.01, 95% CI −9.91 to −1.16) less contrast was delivered in the ACIST group than in the manual group, using automated injectors for left ventriculography only. However, our meta-analysis did not have the ability to explore the causal role of catheter size on contrast volume or CIN end points. The present study had are some limitations to consider. First, most of the constituent patient population was derived from 2 studies. One study used retrospective data from patients who had received manual injection before ACIs had been available at their hospital; thus, most of the cohort was in the manual injection group.5Gurm H.S. Smith D. Share D. Wohns D. Collins J. Madala M. Koneru S. Menees D. Chetcuti S. Impact of automated contrast injector systems on contrast use and contrast-associated complications in patients undergoing percutaneous coronary interventions.JACC Cardiovasc Interv. 2013; 6: 399-405Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar, 14Godley II, R.W. Joshi K. Breall J.A. A comparison of the use of traditional hand injection versus automated contrast injectors during cardiac catheterization.J Invasive Cardiol. 2012; 24: 628-630PubMed Google Scholar The other study did not report whether the patients had been randomized.14Godley II, R.W. Joshi K. Breall J.A. A comparison of the use of traditional hand injection versus automated contrast injectors during cardiac catheterization.J Invasive Cardiol. 2012; 24: 628-630PubMed Google Scholar Larger populations will give greater weight when using a fixed effects model. Additionally, the lack of randomization allows for methodologic biases and confounding variables, including the use of catheter size and biplane to reduce contrast use. Two studies were a continuation of each other, with the only difference being 5 additional patients included in the manual injection group.4Chahoud G. Khoukaz S. El-Shafei A. Azrak E. Bitar S. Kern M.J. Randomized comparison of coronary angiography using 4F catheters: 4F manual versus "Acisted" power injection technique.Catheter Cardiovasc Interv. 2001; 53: 221-224Crossref PubMed Scopus (25) Google Scholar, 7Khoukaz S. Kern M.J. Bitar S.R. Azrak E. Eisenhauer M. Wolford T. El-Shafei A. Coronary angiography using 4 Fr catheters with acisted power injection: a randomized comparison to 6 Fr manual technique and early ambulation.Catheter Cardiovasc Interv. 2001; 52: 393-398Crossref PubMed Scopus (31) Google Scholar However, after excluding the second study with the 5 additional patients, we determined that the lower volumes of contrast administered for diagnostic catheterization were still statistically significant. Second, the nature of the studies did not allow for equipoise or blinding; 2 studies reported randomization techniques, 1 of which used a faulty strategy, and none reported the withdrawal or dropout rates, creating an overall low Jadad score (Table 1). Despite the lack of blinding, we do not believe that the study method affected the validity of our analysis. The authors have no conflicts of interest to disclose.
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